An 18-year-old woman comes to the office due to 6 months of painful menstrual periods. The patient's menstrual period began yesterday, and she has severe lower abdominal pain and cramping that has caused her to stay home from school. She has associated headaches, nausea, fatigue, and dizziness. Acetaminophen has not relieved any of these symptoms. Menarche was at age 13, followed by irregular menstrual periods for the first year. Her menstrual periods are now monthly and consist of 4 days of moderate bleeding. The patient is sexually active with her boyfriend. She has no other medical problems. The patient does not use tobacco, alcohol, or illicit drugs.
BMI is 30 kg/m². Pelvic examination and the remainder of the physical examination are within normal limits. Pregnancy test is negative.
Which of the following is the best next step in management of this patient?

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11ec193a_97da_345b_853d_b74f2f7ecc74_MD0002_00 Primary dysmenorrhea is painful menses (eg, cramping) due excessive prostaglandin production (eg, inflammation) that interferes with daily activities. In addition to cramping, patients often have associated fatigue, headache, and nausea. These symptoms typically begin just prior to the onset of menstruation and generally last 2-3 days. Primary dysmenorrhea is a clinical diagnosis based on cyclic pelvic pain (eg, menses) and a normal pelvic examination (eg, no fixed uterus or adnexal mass), suggesting no underlying pathology. These patients can be started on empiric treatment with combination oral contraceptives (OCPs) or nonsteroidal anti-inflammatory drugs (NSAIDs). Patients with persistent symptoms despite 3 months of either NSAIDs or OCPs are started on a dual regimen. Patients with continued pain after 3 months of dual therapy require evaluation with a pelvic ultrasound to assess for secondary causes of pain (eg, adenomyosis) (Choice E). A negative ultrasound is suggestive of endometriosis, which can be confirmed via diagnostic laparoscopy or treated empirically with a GnRH agonist (eg, leuprolide) (Choices B and C). adenomyosis endometriosis (Choice D) Medroxyprogesterone acetate is indicated for management of patients with primary dysmenorrhea who also have a contraindication to OCPs (eg, migraines with auras, hypertension, age >35 with tobacco use). However, side effects such as weight gain limit this medication's usefulness. Educational objective: Primary dysmenorrhea is a common cause of cyclic menstrual pelvic pain. Diagnosis is clinical; patients with cyclic pelvic pain and a normal pelvic examination require no further evaluation. Treatment is with nonsteroidal anti-inflammatory drugs and/or combination oral contraceptives. __________ References: Diagnosis and initial management of dysmenorrhea. (http://www.ncbi.nlm.nih.gov/pubmed/24695505) Primary dysmenorrhea in adolescents: prevalence, impact and recent knowledge. (http://www.ncbi.nlm.nih.gov/pubmed/26841639)

An 18-Year-Old Woman Comes to the Office Due to 6